Hepatitis C in Prison: An Interview with Dr. Rena Fox

by Harry Goldhagen and Denise Baez

Infection with hepatitis viruses is a large problem for persons in prison. Unfortunately, it is the rare investigator who is willing and able to "jump through the hoops" to conduct studies of the incarcerated population (approximately 0.7% of the US population at any one time, according to some estimates). Rena K. Fox, MD, is one such researcher. Along with her colleagues, she is involved in determining how many people in prison are infected with hepatitis C virus (HCV), a stealthy pathogen that can silently damage the liver for years to decades before making its presence known clinically, with cirrhosis, liver failure, hepatocellular carcinoma, and death. Dr. Fox is Assistant Clinical Professor of Medicine at the University of California at San Francisco, and she was gracious enough to make time in her busy schedule to discuss her work in this field. We were able to meet and talk at the 55th Annual Meeting of the American Association for the Study of Liver Diseases (AASLD) in Boston, Massachusetts, November 2004.

Prevalence of HCV Infection Among Prisoners

Angels:
How did you become involved in investigating hepatitis C in prison?

Rena Fox:
My involvement has mostly been in conducting research. I have had patients in the clinic with a prison history, but probably no more than any other university-based physician.

When I joined UCSF almost 5 years ago under a Clinician Educator Fellowship, I began working with Teresa Wright, MD, a leader in the hepatitis field, and Kimberly Paige-Shafer, PhD, an epidemiologist working in hepatitis C. Together we began working on a California state-funded study of hepatitis C in California prisons, a cross-sectional prevalence study. We tested almost 500 people entering prisons. It was voluntary, but almost 80% of the prisoners opted for hepatitis C testing. In fact, more people were interested in testing than we could accommodate in our study. As part of the study, we also conducted one-on-one, detailed interviews with each person tested, asking about risk behaviors and prison history.

We conducted a second study of hepatitis C prevalence, this time focusing on prison staff. We went to several prisons in California and tested staff members: prison guards, housekeepers, medical personal including phlebotomists, and many other people in various job categories. As with the first study, we also interviewed everyone we tested to determine their risk factors for infection.

And in a third study, which is ongoing, we are testing parolees, that is, people coming out of prison, and determining the prevalence of hepatitis C. We are also asking them about the barriers to access of care they face on the outside.

Angels:
And what have you found?

Rena Fox:
We found that the prevalence of hepatitis C among prisoners in California is 34.5%.

Angels:
Wow! Is that ten times the prevalence in the general population?

Rena Fox:
No, it's over 20 times. The prevalence in the general population is 1.8%, and we found more than a third of people in prison are infected. Prevalence studies have been conducted among prisoners in other states, which have found rates in the same range, between 25-40%. And similar studies of prisoners in other countries have found ranges between 35 and 60%.

Angels:
With such a large prison population in the US, one would think the overall prevalence of hepatitis C would be much higher than reported.

Rena Fox:
Unfortunately, the largest epidemiologic study of hepatitis C in the US, the NHANES III study (Third National Health and Nutrition Examination Survey), which was conducted by the Centers for Disease Control and Prevention, was not able to include incarcerated people. The 1.8% rate in the general population does not include prisoners, and prisoners account for about almost 1% of the population. So there were a lot of people who were left out of the estimate.

Angels:
How often are prisoners screened for hepatitis C?

Rena Fox:
They are not screened at all in most facilities. Only one state offers blanket screening for all incoming prisoners. Most states conduct only targeted screening, selecting people who they think are at high risk. But there is no uniform approach to screening, so most people are not getting tested.

Angels:
Most prison administrations presumably don't want to know.

Rena Fox:
Prisoners do want to know their HCV status, as we learned. As for administrators, our study was funded by the California Department of Corrections, seeking this information. The problems for the corrections system is what to do about this high burden of disease.

Angels:
And the staff members as well?

Rena Fox:
Remember, the prison staff have access to healthcare outside of the prison. They have health plans that come with employment, so they can go to their doctor to get tested and treated for hepatitis C. They don't have to worry that unless "we" provide it, they're not getting it. In contrast, prisoners lose their rights. They cannot just go see a doctor when they wish. With prisoners, unless we provide care, they are not getting it.

Angels:
The Supreme Court has stated that prisoners are the only group in the United States that are guaranteed health care, because they are prisoners, and denying them proper care would be cruel and unusual punishment.

Rena Fox:
Prisoners are guaranteed health care, but what that includes is not necessarily what we might consider comprehensive health care.

Occupational Risks to Prison Staff?

Angels:
Why did you test guards and other prison staff, was this your control group?

Rena Fox:
No, the main reason was to determine whether this population is at high risk for HCV infection. Prison workers and others who are in what are perceived as high-risk occupations for blood-borne diseases are concerned about this issue. For instance, health care workers in hospitals work among patients who have infectious diseases, including blood-borne pathogens such as hepatitis C. We hoped to determined the degree of risk due to occupational exposure, even when they use what are known as universal precautions for preventing infection (eg, wearing gloves to avoid exposure to body fluids). When you look at the risk factors for hepatitis C infection, any kind of percutaneous occupational exposure, like a needle stick or an eye splash, is a potential mode of transmission.

Prison workers therefore have a lot of concern that they may be at higher risk for acquiring hepatitis C, because they are working with a population where over a third are infected. And the requirements of the job may require close contact, which can potentially lead to acquiring the infection.

But, in fact, we did not find this. We tested over 1000 prison workers, and their prevalence of hepatitis C virus infections was 2.1%, which is statistically no different than the general population rate of 1.8%. In addition, none of the prison workers who were positive for infection had risks that could be isolated to their occupation.

Angels:
In other words, they became infected by the usual routes.

Rena Fox:
Yes, they all had other typical risk factors for HCV infection, which includes blood transfusion before 1992 or a history of injection drug use. I think that this study should help to reduce their concern, that even though they are in close contact with people who are hepatitis C positive, this does not necessarily mean they are at higher risk than the general population, even for those doing phlebotomies, as long as they use universal precautions.

Risk Factors for Prisoners

Angels:
What did you find in terms of prisoners and risk factors? Did it match what we already know about how people acquire HCV?

Rena Fox:
Yes, the strongest risk factor is the history of injection drug use. An independent risk factor for women in prison was having a male sexual partner who was an injection drug user. Other behaviors that you might think of as being risk factors for prisoners, like tattooing and body piercing, body fluid contact, and cutting and other rituals, did not pan out as independent risk factors. There have been isolated cases reported among prisoners who have acquired hepatitis C from tattooing, but an isolated case does not make for a major risk factor.

However, what we don't know is whether prisoners acquire hepatitis C within prison or in the community. Most people entering prison have been there before. In fact, almost 60% of people who are released from prison return. However, the only way to determine where infection is taking place is to do a cohort study -- you would follow a group of prisoners who entered prison negative for HCV infection and determine how many came out positive. But that is a much more difficult study to do, which is why we conducted a cross-sectional study.

Treatment of HCV in Prison

Angels:
Does the state correctional system in California provide care for HCV-positive prisoners? Given their budget problems, does California have the money to treat hepatitis C, since it is a chronic disease with a long asymptomatic stage?

Rena Fox:The National Commission on Correctional Health Care has a position statement about treating hepatitis C. The CDC has recommendations for treating this population, and the National Institutes of Health (NIH) has stated that the incarcerated are an understudied population. But in terms of what treatment is in fact provided, it varies not only by state but within states as well; each facility is running its own ship. Some treat hepatitis C more aggressively than others. In fact, I recently read that in 1999, 22% of all of the inmates in the US treated for hepatitis C were treated in one facility in Georgia, and a third were treated in 8 facilities in California. This uneven distribution of care could be due to many factors: the level of contact between a medical director of a prison facility and a hepatologist, or his or her comfort level with treatment of hepatitis C. It has not been uniform.

Angels:
Can physicians and researchers be more involved with prison health care?

Rena Fox:
It is extremely difficult for physicians outside of prison administration to have much to do with care or research of prisoners, because of huge barriers meant to protect prisoners. This is especially true for research, but for care as well. Prisoners constitute a population that ethically needs extra protection, because they are captive. If a researcher were to say, "I want to come in and do a research study," prisoner participation wouldn't necessarily be voluntary; they wouldn't have the same freedom to decline research that you or I would. Nor is it likely that physicians outside of prison health care would provide treatment to prisoners.

On the other hand, I think that the recommendations from organizations like the AASLD, NIH, or CDC can encourage corrections to address specific hepatitis C, just like they are addressing, or hopefully addressing, other health care problems. In fact, hepatitis C dwarfs all other health care problems in prisoners. It's far more common than HIV, hepatitis B, asthma, high blood pressure, or diabetes.

Angels:
That is surprising. HIV seems like a huge problem in prisons.

Rena Fox:
Hepatitis C is far more common in the US than is HIV. HIV has a prevalence of approximately 2% among prisoners versus close to 40% for HCV, similar to the ratio in the US overall. Hepatitis C is more easily transmitted by percutaneous methods like needle sharing.

Angels:
What should physicians be doing about hepatitis among prisoners or former prisoners?

Rena Fox:
First of all, patients who have a history of incarceration should be screened for hepatitis C. Physicians should think of incarceration as a risk factor, just like receiving a blood transfusion before 1992. I think physicians should use the same criteria for treatment eligibility for people who have been in prison that we would for any other patients. A history of incarceration does not mean they are not going to be compliant, that they are not going to be interested in their health care, or that they are not motivated to follow through with long-term treatment. We should take patients as they are, without the stigma of prison.

In the bigger picture, any efforts at advocating for increased healthcare for disadvantaged populations would be a good contribution.

About the Authors

Harry Goldhagen is managing editor of Angels in Medicine and can be reached at harry@medangel.org. Denise Baez is associate editor at iMedOptions, LLC.